RESUMEN
BACKGROUND: Intracoronary (IC) administration of glycoprotein IIb/IIIa inhibitors (GPIs) has been studied as an adjunctive therapy to improve outcomes in patients with ST-segment elevation myocardial infarction (STEMI) undergoing percutaneous coronary intervention. In this systematic review and meta-analysis, we aimed to evaluate the efficacy and safety of IC administration of GPIs compared with those of intravenous (IV) administration in patients with STEMI. METHODS: We searched the MEDLINE, Embase, and Cochrane CENTRAL databases for relevant studies published before September 21, 2022. In total, 22 randomized controlled trials involving 7,699 patients were included. RESULTS: The proportions of patients achieving thrombolysis in myocardial infarction grade 3 flow, myocardial blush grade 2/3, and complete ST-segment resolution were significantly higher in the IC group than in the IV group. Major adverse cardiac events (MACE) (RR: 0.54, 95% CI: 0.37-0.80) and heart failure (RR: 0.48, 95% CI: 0.25-0.91) within 1 month were significantly lower in the IC group than in the IV group; however, after 6 months, no difference was observed in MACE risk. Additionally, the risks of death and bleeding did not differ between the two routes of administration. CONCLUSIONS: When considering adjunctive GPI administration for patients with STEMI, the IC route may offer greater benefits than the IV route in terms of myocardial reperfusion and reduced occurrence of MACE and heart failure within 1 month. Nonetheless, when making decisions for IC administration of GPIs, the absence of a benefit for bleeding risk and difficulty accessing the administration route should be considered.
RESUMEN
Progressive ischemic stroke (PIS) is a therapeutic challenge in clinical practice. The present retrospective study aimed to investigate the safety and effectiveness of eptifibatide in the treatment of PIS. The present study enrolled patients with PIS admitted to Xiangtan Central Hospital (Xiangtan, China) between March 2020 and March 2021 with National Institutes of Health Stroke Scale (NIHSS) progression scores of ≥2 points during the initial 72 h. Patients were then divided into two groups according to their different anti-platelet treatment regimens. The control group was administered anti-platelet aggregation with aspirin 100 mg/day, or aspirin 100 mg/day in combination with clopidogrel 75 mg/day, whilst eptifibatide was administered in the eptifibatide group in addition to the treatment regimen used in the control group. Changes in NIHSS scores at the time of progression and 7 days after treatment (∆NIHSS) were used to assess early neurological recovery, and there were no significant differences in ∆NIHSS and adverse reactions between the groups (P>0.05). Subgroup analysis was subsequently performed according to the type of blood vessel that was involved [large artery atherosclerosis (LAA) or small artery occlusion (SAO)]. For the SAO subgroup, the ∆NIHSS in the eptifibatide group was significantly superior to that of the control group (P=0.008), while for the LAA subgroup, there were no significant differences in ∆NIHSS between groups (P=0.334). The present retrospective study found that patients with PIS tolerated eptifibatide treatment well. Eptifibatide exerted different effects on patients with acute PIS involving different types of blood vessels compared with oral antiplatelet drugs. In addition, application of eptifibatide may lead to faster and earlier recovery in patients with SAO, but not in those with LAA. Low-dose eptifibatide is a safe and effective treatment option for patients with PIS caused by SAO.
RESUMEN
INTRODUCTION: The aim of this study was to test the hypothesis that intravenous tirofiban improves functional outcomes without promoting the risk of intracranial hemorrhage (ICH) in stroke secondary to basilar artery occlusion (BAO) receiving endovascular thrombectomy. METHODS: Patients with acute BAO stroke who were treated with endovascular thrombectomy and had tirofiban treatment information were derived from "BASILAR": a nationwide, prospective registry. All eligible patients were divided into tirofiban and no-tirofiban groups according to whether tirofiban was used intravenously. The primary endpoint was the 90-day severity of disability as assessed by the modified Rankin scale score. Safety outcomes were the frequency of ICH and mortality. RESULTS: Of 645 patients included in this cohort, 363 were in the tirofiban group and 282 were in the no-tirofiban group. Thrombectomy with intravenous tirofiban reduced the 90-day disability level over the range of the modified Rankin scale (adjusted common odds ratio, 2.08; 95% confidence interval (CI), 1.45-2.97; p < 0.001). The 90-day mortality of patients in the tirofiban group was lower than that in the no-tirofiban group (41.6% vs. 52.1%; adjusted hazard ratio, 0.60; 95% CI, 0.47-0.77; p < 0.001). The frequency of any ICH (6.7% vs. 13.7%; p = 0.004) and symptomatic ICH (4.8% vs. 10.1%; p = 0.01) in the tirofiban group was significantly lower than that in the no-tirofiban group. CONCLUSIONS: In patients with acute BAO stroke who underwent endovascular treatment, intravenous tirofiban might be associated with favorable outcome, reduced mortality, and a decreased frequency of ICH.
Asunto(s)
Accidente Cerebrovascular Isquémico , Accidente Cerebrovascular , Humanos , Tirofibán/efectos adversos , Arteria Basilar , Resultado del Tratamiento , Accidente Cerebrovascular/diagnóstico por imagen , Accidente Cerebrovascular/terapia , Trombectomía/efectos adversos , Hemorragias Intracraneales/inducido químicamenteRESUMEN
BACKGROUND: Tirofiban is a glycoprotein IIb/IIIa receptor inhibitor that has been shown to be effective in the treatment of acute coronary syndromes. However, it remains unknown whether it improves outcomes in patients with acute ischemic stroke. OBJECTIVE: This trial investigates the efficacy and safety of tirofiban compared with aspirin for acute ischemic stroke within 24 h after symptom onset. METHODS AND DESIGN: The Efficacy and Safety of Tirofiban Compared with Aspirin in the Treatment of Acute Ischemic Stroke (RESCUE BT 2) Trial is an investigator-initiated, prospective, randomized, double-blind, double-dummy, multicenter clinical trial. Up to 1158 eligible patients will be consecutively randomized to receive antiplatelet therapy with tirofiban or aspirin in 1:1 ratio across approximately 100 stroke centers in China. OUTCOMES: The primary endpoint is the proportion of patients with excellent functional outcomes defined as a modified Rankin scale score of 0 to 1 at 90 days after randomization. Lead safety endpoints include mortality at 90 days and symptomatic intracerebral hemorrhage within 48 h after treatment. TRIAL REGISTRY NUMBER: ChiCTR2000029502 (www.chictr.org.cn).
Asunto(s)
Accidente Cerebrovascular Isquémico , Accidente Cerebrovascular , Humanos , Tirofibán/uso terapéutico , Inhibidores de Agregación Plaquetaria/efectos adversos , Accidente Cerebrovascular Isquémico/tratamiento farmacológico , Estudios Prospectivos , Tirosina/uso terapéutico , Aspirina/uso terapéutico , Método Doble Ciego , Resultado del TratamientoRESUMEN
Despite implementation of new interventional techniques and therapeutic advances, elderly patients with acute coronary syndrome (ACS) continue to be susceptible to in-hospital bleeding compared with younger ones. Thus, we investigated the incidence of in-hospital bleeding events and associated risk factors in elderly (≥ 75°years) ACS patients. We also wanted to define the bleeding sites, characteristics, and associated mortality. Bleeding Academic Research Consortium (BARC) classification type 2, 3, or 5 was used to define bleeding events. Overall, 539 patients were included in the study (mean age: 82.5 ± 4.8°years; 282 (52.3%) females). Of these patients, 69 (12.8%) developed in-hospital bleeding. Factors that were independently related with in-hospital bleeding were age (odds ratio (OR): 1.08; 95% confidence interval (CI): 1.011.14, P = .01), acute kidney injury (OR: 3.66; 95% CI: 2.016.69; P < .01), tirofiban (OR: 4.43; 95% CI: 1.7810.99; P < .01), and ticagrelor (OR: 1.93; 95% CI: 1.013.73; P = .04) administration. The urinary tract was the most frequent bleeding site, followed by femoral arteries. In conclusion, ticagrelor and tirofiban should be used with caution in elderly ACS patients.
Asunto(s)
Síndrome Coronario Agudo , Intervención Coronaria Percutánea , Anciano , Anciano de 80 o más Años , Femenino , Hemorragia/inducido químicamente , Hemorragia/epidemiología , Hospitales , Humanos , Masculino , Intervención Coronaria Percutánea/efectos adversos , Inhibidores de Agregación Plaquetaria/efectos adversos , Ticagrelor , Tirofibán/uso terapéutico , Resultado del TratamientoRESUMEN
BACKGROUND: In patients undergoing mechanical thrombectomy (MT), adjunctive antithrombotic might improve angiographic reperfusion, reduce the risk of distal emboli and reocclusion but possibly expose patients to a higher intracranial hemorrhage risk. This study evaluated the safety and efficacy of combined MT plus eptifibatide for acute ischemic stroke. METHODS: This was a propensity-matched analysis of data from 2 prospective trials in Chinese populations: the ANGEL-ACT trial (Endovascular Treatment Key Technique and Emergency Workflow Improvement of Acute Ischemic Stroke) in 111 hospitals between November 2017 and March 2019, and the EPOCH trial (Eptifibatide in Endovascular Treatment of Acute Ischemic Stroke) in 15 hospitals between April 2019 and March 2020. The primary efficacy outcome was good outcome (modified Rankin Scale score 0-2) at 3 months. Secondary efficacy outcomes included the distribution of 3-month modified Rankin Scale scores and poor outcome (modified Rankin Scale score 5-6) and successful recanalization. The safety outcomes included any intracranial hemorrhage, symptomatic intracranial hemorrhage, and 3-month mortality. Mixed-effects logistic regression models were used to account for within-hospital clustering in adjusted analyses. RESULTS: Eighty-one combination arm EPOCH subjects were matched with 81 ANGEL-ACT noneptifibatide patients. Compared with the no eptifibatide group, the eptifibatide group had significantly higher rates of successful recanalization (91.3% versus 81.5%; P=0.043) and 3-month good outcomes (53.1% versus 33.3%; P=0.016). No significant difference was found in the remaining outcome measures between the 2 groups. All outcome measures of propensity score matching were consistent with mixed-effects logistic regression models in the total population. CONCLUSIONS: This matched-control study demonstrated that MT combined with eptifibatide did not raise major safety concerns and showed a trend of better efficacy outcomes compared with MT alone. Overall, eptifibatide shows potential as a periprocedural adjunctive antithrombotic therapy when combined with MT. Further randomized controlled trials of MT plus eptifibatide should be prioritized. REGISTRATION: URL: https://www. CLINICALTRIALS: gov; Unique identifier: NCT03844594 (EPOCH), NCT03370939 (ANGEL-ACT).
Asunto(s)
Isquemia Encefálica , Accidente Cerebrovascular Isquémico , Accidente Cerebrovascular , Isquemia Encefálica/tratamiento farmacológico , Isquemia Encefálica/cirugía , Eptifibatida , Humanos , Hemorragias Intracraneales/etiología , Estudios Prospectivos , Accidente Cerebrovascular/tratamiento farmacológico , Accidente Cerebrovascular/cirugía , Trombectomía/métodos , Resultado del TratamientoRESUMEN
BACKGROUND: Tirofiban, a glycoprotein IIb/IIIa receptor inhibitor, has been shown to reduce the risk of thrombotic complications during percutaneous coronary intervention. However, it remains unknown whether tirofiban improves outcomes in large vessel occlusion stroke patients undergoing endovascular treatment. OBJECTIVE: This trial aims to assess whether additional intravenous tirofiban therapy can improve the clinical outcomes in large vessel occlusion stroke patients who undergo endovascular treatment within 24 h of symptom onset. METHODS AND DESIGN: The Endovascular Treatment With versus Without Tirofiban for Stroke Patients With Large Vessel Occlusion (RESCUE BT) Trial is an investigator-initiated, randomized, placebo-controlled, double-blind, multicenter trial. Up to 930 eligible patients will be consecutively randomized to intravenous tirofiban or placebo in 1:1 ratio over 3 years across 50 endovascular-capable stroke centers in China. OUTCOMES: The primary end point is the disability level as measured by overall distribution of the 90-day modified Rankin Scale scores. Primary safety end points include symptomatic intracerebral hemorrhage at 48 h and mortality at 90 days. TRIAL REGISTRY NUMBER: ChiCTR-INR-17014167 (www.chictr.org.cn).
Asunto(s)
Arteriopatías Oclusivas , Accidente Cerebrovascular , Humanos , Tirofibán/uso terapéutico , Accidente Cerebrovascular/tratamiento farmacológico , Tirosina/uso terapéutico , Método Doble Ciego , Resultado del Tratamiento , Ensayos Clínicos Controlados Aleatorios como Asunto , Estudios Multicéntricos como AsuntoRESUMEN
Organization of platelet-rich thrombus at the site of plaque disruption may contribute to rapid progression of atherosclerosis. This study was conducted to investigate if potent platelet inhibition therapy in patients with acute coronary syndromes (ACS) mitigates plaque progression. Patients enrolled in the EROSION study who presented with ACS caused by plaque erosion and underwent serial imaging of the culprit lesion by optical coherence tomography at baseline, 1 month, and 1 year were included. Among 49 patients, 32 (65.3%) patients were treated with glycoprotein IIb/IIIa inhibitor (GPI) in addition to aspirin and ticagrelor. The increase in area stenosis from baseline to 1-year follow-up was significantly smaller in patients treated with GPI, compared to those without GPI therapy (4.8% [- 1.6 to 10.9] vs. 9.6% [4.0 to 21.3], p = 0.031). The cohort was divided into 2 groups based on culprit lesion phenotype at 1 year: Group A, new layer formation at 1-year that was not present at baseline (n = 18); Group B, no new layer formation (n = 31). A new layer was less frequently found at 1 year in patients treated with GPI than in those without GPI (25.0% vs. 58.8%, p = 0.019). Group A, compared to Group B, was associated with a greater increase in area stenosis (19.0 ± 16.4% vs. 3.7 ± 7.1%; p < 0.001). Potent platelet inhibition with GPI in patients with ACS caused by plaque erosion was associated with lower incidence of new layer formation and less plaque progression.
Asunto(s)
Síndrome Coronario Agudo , Aterosclerosis , Placa Aterosclerótica , Síndrome Coronario Agudo/complicaciones , Angiografía Coronaria/métodos , Humanos , Placa Aterosclerótica/complicaciones , Placa Aterosclerótica/tratamiento farmacológico , Tirofibán/uso terapéutico , Tomografía de Coherencia Óptica/métodosRESUMEN
A variety of antithrombotic drugs are used during percutaneous coronary interventions (PCIs). We aimed to investigate the practicability of the use of bivalirudin and GPIs in patients receiving PCI. We searched 7 of 629 relevant records from PubMed, the Cochrane Library, EMBASE, and Web of Science for randomised controlled trials. There were no significant differences in the rates of major adverse cardiac events (MACE) between bivalirudin plus GPI and heparin (all P â> â.05). Bivalirudin plus planned GPI was similar to bivalirudin monotherapy in terms of the risk of MACE (risk ratio [RR] = 1.07; 95% confidence interval [CI] = .91 - 1.27; P = .55). Bivalirudin plus provisional GPI was associated with lower bleeding risk (RR = .57; 95% CI = .47 - .69; P < .01) compared to using heparin plus GPI. Compared to bivalirudin alone, bivalirudin plus planned GPI evidently increased bleeding risk (RR = 2.20; 95% CI = 1.73 - 2.79; P < .01). Patients receiving bivalirudin or heparin therapy had semblable efficacy endpoints, but those receiving bivalirudin had a significantly lower bleeding risk. For high-risk bleeding patients, bivalirudin plus provisional GPI can have a better antithrombotic effect than heparin, without increasing the bleeding risk.
Asunto(s)
Antitrombinas/uso terapéutico , Fragmentos de Péptidos/uso terapéutico , Intervención Coronaria Percutánea/métodos , Complejo GPIIb-IIIa de Glicoproteína Plaquetaria/antagonistas & inhibidores , Antitrombinas/farmacología , Femenino , Hirudinas/farmacología , Humanos , Masculino , Fragmentos de Péptidos/farmacología , Proteínas Recombinantes/farmacología , Proteínas Recombinantes/uso terapéutico , Resultado del TratamientoRESUMEN
BACKGROUND: Studies investigating the modulators of mortality benefit conferred by peri-angioplasty glycoprotein IIb/IIIa inhibitors in ST-elevation myocardial infarction (STEMI) are still lacking.MethodsâandâResults:A prospective database (n=1,025) of consecutive cases undergoing primary percutaneous coronary intervention for STEMI was retrospectively analyzed. For patients in Killip class I, II or III, IV, the multivariate-adjusted hazard ratios of 30-day all-cause mortality associated with adjunctive tirofiban were 3.873 (95% CI 0.504-29.745; P=0.193), 0.550 (95% CI 0.188-1.609; P=0.275), and 0.264 (95% CI 0.099-0.704; P=0.008), respectively. The P value for a linear trend was 0.032. Patients who had a body mass index (BMI) within 22.9-25.0 kg/m2had a significant benefit from tirofiban (adjusted HR 0.344; 95% CI 0.145-0.814; P=0.015) compared to other BMI groups. The P value for a quadratic trend was 0.012. A novel Killip-BMI score (KBS = 2.5 × Killip category - | BMI - 24 |) was calculated to select the beneficial population. A KBS ≥2 was associated with significant mortality benefit, whereas a KBS <0 predicted increased 30-day mortality with tirofiban use. CONCLUSIONS: Survival benefit from peri-angioplasty tirofiban therapy for STEMI was positively correlated with the Killip class. Tirofiban should be used cautiously in either underweight or overweight patients. The novel KBS used in this study can guide peri-angioplasty use of adjunctive tirofiban in patients with STEMI undergoing primary angioplasty.
Asunto(s)
Angioplastia Coronaria con Balón , Intervención Coronaria Percutánea , Infarto del Miocardio con Elevación del ST , Tirofibán/uso terapéutico , Humanos , Inhibidores de Agregación Plaquetaria/uso terapéutico , Estudios Retrospectivos , Infarto del Miocardio con Elevación del ST/tratamiento farmacológico , Infarto del Miocardio con Elevación del ST/mortalidad , Infarto del Miocardio con Elevación del ST/cirugía , Resultado del TratamientoRESUMEN
PURPOSE: Thrombosis is one of the main complications of endovascular treatment for unruptured intracranial aneurysms (UIA). This article reports the timing and initial location of thrombosis and prognosis after the use of tirofiban for performing coil embolization for UIA. METHODS: This study retrospectively collected 1686 cases of intracranial aneurysms treated with coil embolization from January 2013 to February 2018. Ruptured cases were excluded. The presumed causes and timing of thrombosis, the response after tirofiban administration and the modified Rankin scale (mRS) score at 3 months were reviewed. RESULTS: Of the 26 patients 76% were female and middle cerebral artery and basilar artery aneurysms accounted for 7 cases. The initial location of thrombosis was related to the stent (nâ¯= 14, 53.8%) or coil (nâ¯= 12, 46.2%). Of the patients 19 (73.1%) developed thrombosis during the procedure, and 5 patients (19.2%) developed it within 1 day of the procedure. Median duration between the thrombotic procedure and initial thrombosis was 38.5â¯min, 12 patients were symptomatic but more than half completely recovered after using tirofiban. Good clinical outcome (mRS 0-2) was seen in 92.3%. In the subgroup analysis, median time from the first thrombotic procedure to initial thrombosis within 1 day was 38.0â¯min (stent-related group) and 35.0â¯min (coil-related group, pâ¯= 0.651). CONCLUSION: In most cases of embolization for UIA, thrombosis requiring the use of tirofiban occurs intraprocedurally or on the first day after the procedure. Careful observation of thrombosis during the procedure is important and tirofiban should be used for a better outcome even if the infarction progresses.
Asunto(s)
Aneurisma Roto , Embolización Terapéutica , Aneurisma Intracraneal , Trombosis , Aneurisma Roto/terapia , Embolización Terapéutica/efectos adversos , Femenino , Humanos , Aneurisma Intracraneal/diagnóstico por imagen , Aneurisma Intracraneal/terapia , Estudios Retrospectivos , Stents/efectos adversos , Tirofibán , Resultado del TratamientoRESUMEN
Evidence for the use of glycoprotein IIb/IIIa inhibitors (GPIs) in the management of acute coronary syndrome (ACS) is from the era of either limited utilization of P2Y12 inhibitors or prior the introduction of more potent P2Y12 inhibitors. This leads to divergent opinions regarding the role of these agents in contemporary practice. This study sought the opinion of cardiovascular clinical pharmacists regarding the role of GPIs in the modern of ACS management. A 13-question survey was created and distributed from June 2018 to July 2018 via the American College of Clinical Pharmacy's Cardiology Practice and Research Network e-mail listserv. The survey consisted of questions regarding the ideal use of GPIs in ACS management, preferred agent selection, and rational for selection. All results were analyzed with descriptive statistics. There were a total 69 responses of 1175 (response rate 5.9%). The majority felt there was still a role for GPI in accordance to the American College of Cardiology (ACC)/American Heart Association (AHA) guidelines for ST-segment elevation myocardial infarction (65.2%), with eptifibatide being preferred (55.1%). For non-ST-segment myocardial infraction (NSTEMI), only 49.3% felt role of GPI was in line with the ACC/AHA guidelines, but a notable number of respondents felt GPIs were only indicated in NSTEMI patients for bailout or thrombotic complications (18.8%). A majority (56.5%) felt GPIs could be used as an alternative for cangrelor when bridging. The decision to use one agent over another were efficacy data, cost, and pharmacokinetic profile.
Asunto(s)
Síndrome Coronario Agudo , Síndrome Coronario Agudo/diagnóstico , Síndrome Coronario Agudo/tratamiento farmacológico , Humanos , Farmacéuticos , Inhibidores de Agregación Plaquetaria , Complejo GPIIb-IIIa de Glicoproteína Plaquetaria , Encuestas y CuestionariosRESUMEN
BACKGROUND: Out of hospital cardiac arrest (OHCA) patients requiring percutaneous coronary intervention (PCI) are at higher risk of both stent thrombosis and bleeding. The use of aggressive antiplatelet therapy could lead to a higher risk of bleeding in these patients. Indeed, data on glycoprotein IIb/IIIa inhibitor (GPi) use in this specific indication is scarce. AIM: We sought to evaluate the benefit and safety of GPi use in OHCA patients requiring PCI. METHODS AND RESULTS: Between January 2007 and December 2017, we retrospectively included all consecutive patients treated with PCI for an OHCA from cardiac cause. Clinical, procedural data and in-hospital outcomes were collected. Three hundred and eighty-five patients were included. GPi were administrated in 41.3% of cases (159 patients). Patients who received GPi were younger, had less prior PCI, more often a TIMI 0 or 1 flow before PCI and thromboaspiration use. There were no differences regarding in-hospital definite stent thrombosis among the two groups (11.9% in the GPi group vs 7.1% in the non-GPi group, pâ¯=â¯0.10) or in-hospital mortality (48.6% vs 49.3%, pâ¯=â¯0.68). The incidence of any bleeding (33.3% vs. 19.6%; pâ¯=â¯0.002), and major bleeding (BARC 3-5) (21.9% vs. 16.8%; pâ¯=â¯0.007) was significantly higher in patients receiving GPi. Indeed, using multivariate analysis, GPi use was predictor of major bleeding (OR: 1.81; 95% CI: 1.06-3.08; pâ¯=â¯0.03). CONCLUSIONS: In patients treated with PCI for OHCA from cardiac cause, GPi use was associated with an increased risk of major bleeding events, without difference on in-hospital stent thrombosis or death.
Asunto(s)
Paro Cardíaco Extrahospitalario , Intervención Coronaria Percutánea , Humanos , Paro Cardíaco Extrahospitalario/terapia , Inhibidores de Agregación Plaquetaria/efectos adversos , Complejo GPIIb-IIIa de Glicoproteína Plaquetaria , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
Background and Purpose: The incidence of acute intraprocedural stent thrombosis (AIST) during stenting of intracranial atherosclerotic stenosis (ICAS) has seldom been reported and evidence regarding the treatment of AIST is lacking. We aim to investigate the incidence of AIST during stenting of ICAS in our institute, assess the preliminary efficacy and safety of rescue treatment of tirofiban for these patients. Methods: From September 2016 to May 2019, all symptomatic ICAS patients who underwent intracranial stenting in our institute were prospectively registered into this study, of which patients with AIST were retrospectively reviewed to extract baseline characteristics, perioperative management, procedural details, angiographic, and clinical outcomes. Rescue treatment of tirofiban for AIST was assessed by recanalization of the culprit vessel and periprocedural death, hemorrhage, and ischemic stroke. Results: Acute intraprocedural stent thrombosis developed in 12 (6.2%) patients within 30 min after stent placement of 194 patients. All 12 cases were successfully recanalized with modified Treatment in Cerebral Ischemia (mTICI) 3 and Arterial Occlusive Lesion (AOL) 3 after rescue treatment of tirofiban alone. There was no perioperative death or any hemorrhagic complication. Three patients suffered perioperative ischemic stroke. Conclusions: We observed a non-negligible rate of AIST during intracranial stenting procedures for ICAS. Intra-arterial bolus followed by intravenous tirofiban infusion seems to be efficacious and safe for AIST during stent placement for ICAS, without increasing the rate of hemorrhagic complications and death.
RESUMEN
BACKGROUND: For patients with ST-segment elevation myocardial infarction (STEMI) undergoing percutaneous coronary intervention (PCI), the efficacy and safety of novel P2Y12 antagonists, including prasugrel or ticagrelor, has not been established relative to that of the clopidogrel-based triple-antiplatelet treatments (TAPTs; in combination with glycoprotein IIb/IIIa inhibitor). The present meta-analysis evaluated the efficacy and safety of prasugrel- or ticagrelor-based TAPTs relative to that of clopidogrel TAPTs in patients with STEMI undergoing PCI. METHODS: The databases PubMed, Embase, and Cochrane's Library were systematically searched for relevant randomized controlled trials concerning prasugrel or ticagrelor (test) relative to clopidogrel (control). Depending on heterogeneity, studies were pooled with a random effects or a fixed effects model. Outcomes of blood flow after PCI were evaluated, including TIMI (thrombolysis in myocardial infarction), bleeding events, and major adverse cardiovascular events (MACEs). RESULTS: Seven studies comprising 11,874 patients conformed to the inclusion criteria. The pooled results with the fixed effects model indicated that after PCI patients in the prasugrel or ticagrelor groups were as likely as those treated with clopidogrel to achieve TIMI grade 3 flow or experience bleeding events. However, compared with the control, the test groups had significantly less risk of MACE (OR: 0.81, 95% CI: 0.70-0.94, P = 0.004), especially at the 1-year follow-up (OR: 0.79, 95% CI: 0.66-0.95, P = 0.01). CONCLUSIONS: A prasugrel- or ticagrelor-based TAPT may reduce the rate of MACEs, without increasing bleeding in STEMI patients undergoing PCI. However, due to the limited RCT studies and variations in study weight, results of this meta-analysis should be confirmed in a large RCT with adequate sample size and follow-up duration.
Asunto(s)
Clopidogrel/uso terapéutico , Intervención Coronaria Percutánea , Inhibidores de Agregación Plaquetaria/uso terapéutico , Complejo GPIIb-IIIa de Glicoproteína Plaquetaria/antagonistas & inhibidores , Clorhidrato de Prasugrel/uso terapéutico , Antagonistas del Receptor Purinérgico P2Y/uso terapéutico , Infarto del Miocardio con Elevación del ST/terapia , Ticagrelor/uso terapéutico , Anciano , Anciano de 80 o más Años , Clopidogrel/efectos adversos , Quimioterapia Combinada , Femenino , Hemorragia/inducido químicamente , Humanos , Masculino , Persona de Mediana Edad , Intervención Coronaria Percutánea/efectos adversos , Intervención Coronaria Percutánea/mortalidad , Inhibidores de Agregación Plaquetaria/efectos adversos , Clorhidrato de Prasugrel/efectos adversos , Antagonistas del Receptor Purinérgico P2Y/efectos adversos , Recurrencia , Factores de Riesgo , Infarto del Miocardio con Elevación del ST/mortalidad , Ticagrelor/efectos adversos , Resultado del TratamientoAsunto(s)
Síndrome Coronario Agudo/terapia , Angioplastia Coronaria con Balón , Estenosis Coronaria/terapia , Trombosis Coronaria/terapia , Inhibidores de Agregación Plaquetaria/administración & dosificación , Antagonistas del Receptor Purinérgico P2Y/administración & dosificación , Trombectomía , Síndrome Coronario Agudo/diagnóstico por imagen , Adulto , Angioplastia Coronaria con Balón/instrumentación , Anticoagulantes/administración & dosificación , Estenosis Coronaria/diagnóstico por imagen , Trombosis Coronaria/diagnóstico por imagen , Stents Liberadores de Fármacos , Humanos , Masculino , Succión , Resultado del TratamientoRESUMEN
To investigate the potential effect of intracoronary administration of the glycoprotein IIb/IIIa inhibitor tirofiban on the microvascular obstruction (MVO) assessed by cardiac magnetic resonance (CMR) imaging compared to the intravenous route in patients with ST-segment-elevation myocardial infarction undergoing primary percutaneous coronary intervention (PCI). Two hundred eight patients were randomized into two groups (tirofiban i.v. and tirofiban i.c.). CMR was completed within 3-7 days after ST-segment-elevation myocardial infarction. One hundred thirty-two patients had a follow-up CMR at 6 months after discharge. The primary end point was the CMR measurements including myocardium strain, myocardial perfusion index, final infarct size, prevalence and extent of MVO, and the change of left ventricular end-diastolic volume (LVEDV) at six months follow-up. The second endpoint was major adverse cardiovascular events (composite of all-cause death, nonfatal reinfarction and congestive heart failure) in one year. The MVO prevalence and extent [56% versus 36%, p = 0.004; 2.08 (IQR: 1.18-5.07) g versus 1.68 (IQR: 0.30-3.28) g, p = 0.041] showed a significant difference between the intravenous and intracoronary groups. Global left ventricular peak longitudinal strain was significantly different in intracoronary groups compared to intravenous groups, - 12.5 [IQR: - 13.4 to - 10.9] versus - 12.3 [IQR: - 13.4 to - 10.4], respectively (P = 0.042). Infarcted myocardial perfusion index was significantly different in intracoronary groups compared to intravenous groups, 0.11 [IQR: 0.08 to 0.15] versus 0.09 [IQR: 0.07 to 0.14], respectively (P = 0.026). Intracoronary tirofiban was associated with a higher change in LVEDV compared with intravenous group (- 10.2% [IQR: - 13.7% to - 2.6%] versus 1.3% [IQR: - 5.6% to 6.1%], p < 0.001). Intracoronary tirofiban application showed no benefit on the occurrence of major adverse cardiovascular events during follow-up compared to intravenous administration. This CMR study in ST-segment-elevation myocardial infarction patients showed a benefit in MVO and left ventricular remodeling for intracoronary tirofiban administration compared to intravenous administration in patients undergoing PCI.
Asunto(s)
Circulación Coronaria/efectos de los fármacos , Imagen por Resonancia Cinemagnética , Microcirculación/efectos de los fármacos , Daño por Reperfusión Miocárdica/prevención & control , Intervención Coronaria Percutánea , Inhibidores de Agregación Plaquetaria/administración & dosificación , Infarto del Miocardio con Elevación del ST/terapia , Tirofibán/administración & dosificación , Administración Intravenosa , Adulto , China , Femenino , Humanos , Masculino , Persona de Mediana Edad , Daño por Reperfusión Miocárdica/diagnóstico por imagen , Daño por Reperfusión Miocárdica/mortalidad , Daño por Reperfusión Miocárdica/fisiopatología , Intervención Coronaria Percutánea/efectos adversos , Intervención Coronaria Percutánea/mortalidad , Inhibidores de Agregación Plaquetaria/efectos adversos , Complejo GPIIb-IIIa de Glicoproteína Plaquetaria/antagonistas & inhibidores , Valor Predictivo de las Pruebas , Estudios Prospectivos , Infarto del Miocardio con Elevación del ST/diagnóstico por imagen , Infarto del Miocardio con Elevación del ST/mortalidad , Infarto del Miocardio con Elevación del ST/fisiopatología , Factores de Tiempo , Tirofibán/efectos adversos , Resultado del Tratamiento , Función Ventricular Izquierda/efectos de los fármacos , Remodelación Ventricular/efectos de los fármacosRESUMEN
For recanalization of emergent large vessel occlusions (ELVOs), endovascular therapy (EVT) using newer devices, such as a stent retriever and large-bore catheter, has shown better patient outcomes compared with intravenous recombinant tissue plasminogen activator only. Intracranial atherosclerotic stenosis (ICAS) is a major cause of acute ischemic stroke, the incidence of which is rising worldwide. Thus, it is not rare to encounter underlying ICAS during EVT procedures, particularly in Asian countries. ELVO due to underlying ICAS is often related to EVT procedure failure or complications, which can lead to poor functional recovery. However, information regarding EVT for this type of stroke is lacking because large clinical trials have been largely based on Western populations. In this review, we discuss the unique pathologic basis of ELVO with underlying ICAS, which may complicate EVT procedures. Moreover, we review EVT data for patients with ELVO due to underlying ICAS and suggest an optimal endovascular recanalization strategy based on the existing literature. Finally, we present future perspectives on this subject.
Asunto(s)
Procedimientos Endovasculares/métodos , Arteriosclerosis Intracraneal/cirugía , Constricción Patológica , Humanos , Complejo GPIIb-IIIa de Glicoproteína Plaquetaria/antagonistas & inhibidores , Stents , Accidente Cerebrovascular/cirugía , TrombectomíaRESUMEN
Current guidelines emphasize the need for at least 6-12 months of oral dual antiplatelet therapy consisting of aspirin and a P2Y12 inhibitor following drug-eluting coronary artery stent implantation. In patients with recently implanted coronary artery stents who require urgent cardiac or noncardiac surgery, the benefits of maintaining oral dual antiplatelet therapy must be carefully weighed against the risks of excessive bleeding, and current practice is largely guided by individual surgeon preferences. When the effects of a second oral antiplatelet agent are undesirable during the perioperative period, the use of a short-acting intravenous antiplatelet agent as "bridge" therapy that can be discontinued shortly before surgery is associated with a reduced occurrence of adverse clinical events in patients with recently implanted coronary stents requiring urgent coronary artery bypass graft surgery. Cangrelor is an intravenous adenosine triphosphate analog P2Y12 receptor antagonist with a short plasma half-life that has been used off label in patients with recent coronary stents as a bridge to invasive procedures with excessive bleeding risk. To our knowledge, this is the first case report to demonstrate the safe and effective use of cangrelor as a bridge to left ventricular assist device implantation in a patient with a recently implanted drug-eluting coronary artery stent who developed acute thrombocytopenia following reexposure to tirofiban, a glycoprotein IIb/IIIa inhibitor.